Vascular Complications in Transcatheter Aortic Valve Replacement With Plug-Based vs Suture-Based Closure Devices

Dual ProGlide vs ProGlide and Angio-Seal for Femoral Access Hemostasis After Transcatheter Aortic Valve Replacement: A Randomised Comparative Trial

BACKGROUND

Vascular complications increase morbidity and mortality after transcatheter aortic valve replacements (TAVR), often related to failures in vascular closure devices (VCDs). We intended to compare the dual Perclose ProGlide (PP) strategy and the hybrid combination of PP and Angio-Seal (AS) for femoral access hemostasis after TAVR.

METHODS

A randomised controlled trial with 257 patients comparing dual PP with 1 PP and 1 AS (AS+PP) for vascular closure after transfemoral TAVR was conducted. The primary end point was the composite of TAVR access site-related vascular complications and life-threatening type 2/3 or 1 bleeding according to the Valve Academic Research Consortium 3. Secondary end points included additional VCD use and significant peripheral ischemia related to arteriotomy closure within 1 year. Modified VCD failure, defined as failure to achieve hemostasis within 5 minutes or requiring additional endovascular manoeuvres, was also recorded.

RESULTS

The AS+PP combination yielded lower rates of the primary end point (18.2% vs 29.8%; P = 0.0381), vascular complication (18.2% vs 29.8%; P = 0.0381), additional VCD use (0.8% vs 19.0%; P < 0.0001), and modified VCD failure (9.9% vs 33.1%; P < 0.0001) than the dual PP. Bleeding complication rates were similar between the 2 groups. Three-month follow-up vascular duplex tests showed similar common femoral artery (CFA) diameters and peak systolic velocities (PSVs) between the 2 groups, but those with additional intervention had higher PSVs and smaller CFA diameters than those without.

CONCLUSIONS

Combined PP+AS for large-bore femoral access hemostasis after TAVR promises to be more effective and safer than dual PP in terms of vascular complications. Moreover, additional intervention for vascular complications resulted in smaller CFA diameters.

CLINICAL TRIAL REGISTRATION

NCT05491070.

Impact of Sex on Outcomes With Femoral Artery Closure Devices Versus Manual Compression in Patients Undergoing Percutaneous Coronary Intervention

Background and Aims

Femoral artery access is widely used despite recent increase in radial access for percutaneous coronary interventions (PCI). Femoral artery closure devices are used to shorten vascular closure time and reduce bleeding. We sought to examine sex-based outcomes of femoral artery vascular closure devices (VCD) in patients undergoing PCI.

Methods

We identified patients who had undergone PCI (n = 11,415) in the Indiana University Health Multicenter Cardiac Cath registry using femoral artery access. Clinical outcomes were compared between VCD and manual compression and analyzed according to sex. Patients with cardiogenic shock and left ventricular support devices were excluded.

Results

The use of any vascular closure device as compared to femoral artery manual compression was associated with a reduction in 72-h bleeding events (adjusted odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.46-0.87). With manual compression, women had higher rates of 72-h bleeding as compared to men (4.5% vs. 1.6%, p < 0.001). Women demonstrated greater absolute risk reduction in 72-h bleeding events with use of VCD as compared to men (2.8% vs. 0.8%, p < 0.001). For women, VCD were associated with lower risk of access site bleeding (OR: 0.43; 95% CI: 0.24-0.8), hematoma (OR: 0.36; 95% CI: 0.2-0.63), and vascular complications (OR: 0.25, 95% CI: 0.09-0.72). Use of VCD was associated with lower risk of in-hospital death (adjusted OR: 0.4; 95% CI: 0.28-0.58; p < 0.001) in multivariable regression analysis.

Conclusion

Women derive more benefit from use of femoral artery VCD during PCI than men with greater reduction in bleeding rates, access site hematoma, and vascular complications.

ProGlide-AngioSeal versus ProGlide-FemoSeal for vascular access hemostasis posttranscatheter aortic valve implantation

BACKGROUND

The hybrid strategy combining plug-based and suture-based vascular closure devices (VCD) was introduced as a promising technique for vascular access hemostasis after transcatheter aortic valve implantation (TAVI) with satisfactory outcomes. However, data comparing two plug-based VCDs each in the combination with a suture-based VCD, namely ProGlide/AngioSeal (P/AS) with ProGlide/FemoSeal (P/FS) VCDs, is still lacking.

AIMS

To compare the 30-day outcome of the hybrid strategy using P/AS versus P/FS for vascular access site closure after TAVI.

METHODS

A retrospective single-center observational study included 608 patients recruited from a prospective TAVI registry between 2016 and 2022. The composite endpoint was defined as any VCD-related major vascular complications and/or bleeding more than type 1 according to Valve Academic Research Consortium criteria.

RESULTS

The current study reported a significantly higher rate of composite endpoint in P/AS group, which was driven by a higher rate of major bleeding (5.4% vs. 1.4%, p = 0.036). We also found a higher rate of VCD-related minor bleeding in P/AS group (16.3% vs. 8.1%, p = 0.013). Successful access site hemostasis was achieved in 71.7% of P/AS group versus 83.1% in P/FS group (p = 0.006). The presence of anterior wall calcification at the access site was significantly associated with the composite endpoint (adj odds ratio 2.49; 95% confidence interval (1.08-5.75), p = 0.032).

CONCLUSION

The hybrid strategy for large bore vascular access closure using P/FS showed a potentially better 30-day outcomes compared with P/AS. The presence of anterior calcification at the access site carries a significant risk of VCD-related complications.

The interventional care for patients undergoing transcatheter aortic valve replacement: Establishing indicators for optimal interventional care

OBJECTIVE

We evaluate the quality of interventional care for patients undergoing transcatheter aortic valve replacement (TAVR) using a set of quality indicators.

METHODS

We developed an initial list of quality indicators by incorporating current guidelines, observing practice discrepancies, and basing it on the Donabedian "structure, process, and outcome" three-dimensional quality evaluation model as the framework. The Delphi method was utilized in two rounds of consultation involving 31 experts to evaluate and revise indicators at all levels.

RESULTS

The response rate of expert questionnaires was 100% for both rounds, and the expert authority coefficients were 0.913 and 0.940, respectively. The Kendall harmony coefficients were 0.221 and 0.195, respectively, with P < 0.05. Eventually, a quality evaluation system of interventional care for patients undergoing TAVR was constructed, consisting of three structural indicators, nine process indicators, and 42 outcome indicators.

CONCLUSIONS

The quality evaluation system for interventional care of TAVR sought to establish specific, objective, and quantifiable criteria for assessing the quality of care. It is recommended to apply the set of quality indicators across hospitals to enhance the quality of care for TAVR.