Short and long-term results after endovascular management of vascular complications during transfemoral aortic valve implantation

Midterm Outcome of Balloon-Expandable Covered Stenting of Femoral Access Site Complications

Background: Vascular access site complications (VASCs) after endovascular interventions requiring a large-bore access are frequent and known to be associated with increased morbidity and mortality. Although balloon-expandable covered stents (BECSs) are increasingly used in such indications, their performance in this rather hostile territory is currently unknown. We aimed to evaluate the safety and efficacy of BECSs in common femoral artery (CFA) VASCs management. Methods: This is a national multicenter retrospective study of all patients who underwent BECS implantation of the CFA due to a VASCs after an endovascular procedure between January 2020 and May 2023 in major tertiary referral centers in Hungary. Operative data were collected and follow-up ultrasound examinations were performed. Our study is registered on ClinicalTrials.gov (NCT05220540) and followed the STROBE guidelines. Results: Of the 23 patients enrolled (13 females, mean age: 74.2 ± 8.6), technical success was achieved in 21 (91.3%) cases, with one perioperative death. After an average follow-up of 18.0 ± 11.4 months, another nine (39.1%) deaths occurred, and one was VASCs-associated. BECS occlusion was detected in one (4.3%) patient, being the only reintervention (4.3%) where revascularization was also achieved. Conclusions: Although BECS implantation for CFA VASCs is feasible with a relatively high technical success rate, the mortality rate is non-negligible. Until adequately evaluated, BECS implantation in such indications is to be used with caution, ideally only within the framework of a trial.

Outcomes of Using Balloon-Expandable Covered Stent for Percutaneous Treatment of Access-Site Vascular Injury after Transfemoral Aortic Valve Implantation: A Single Center Experience

BACKGROUND

Access-site vascular injury (ASVI) remains a challenge for transfemoral transcatheter aortic valve implantation (TAVI). Although surgery is the gold standard, endovascular therapy gains growing acceptance as primary treatment option for ASVI. The aim of this study was to analyze the safety and efficacy of covered balloon-expandable stents (BXSs) placement for ASVI after transfemoral TAVI.

METHODS

All patients treated with a covered BXS between January 2018 and December 2020 for access-site related bleeding complications following femoral TAVI were included in this single center retrospective study. Primary measure outcome of this study was the primary patency at 12 months. Technical success, limb clinical worsening and device related complications were additionally analyzed.

RESULTS

During the study period, 576 percutaneous femoral TAVIs were performed. Of these, 36 patients (6%) underwent covered stent deployment for a femoral access-site complication (19 men, median age 83 years old). Procedural success was 97%. The median follow-up was 12 months (interquartile range [IQR] = 9.7, range 0-36 months). One patient was lost to follow-up. The primary patency rates at 6 and 12 months were 100% and 95% respectively. No clinical deterioration or stent fracture was described during this period.

CONCLUSIONS

Our results suggest that covered BXS deployment is a safe and effective alternative to surgery and may be a promising option for treating ASVI after femoral TAVI.

Surgical Versus Interventional Treatment of Major Access Site Complications During Transfemoral TAVI Procedures at a Large Volume Center

PURPOSE

Access-related vascular complications in transfemoral transcatheter aortic valve implantation (TAVI) can be treated endovascularly or surgically. The aim of this study was to evaluate the short- and long-term outcomes of endovascular treatment compared with surgical repair for access-related vascular complications.

METHODS

This retrospective study was performed from January 1, 2018, to December 31, 2020. All transfemorally treated TAVI patients in whom a surgical or endovascular treatment for an access site complication was needed were included. The primary outcome was the need for any related vascular re-operation.

RESULTS

In total, 1219 transfemoral TAVI procedures were conducted during the study period. 19 patients suffered an access complication requiring endovascular treatment, while 54 patients required surgical repair. No differences were seen with regard to re-operations (endovascular 15.8% vs surgical 14.8%; p=0.919), wound infections (endovascular 0% vs surgical. 11.1%; p=0.129), and wound healing disorders (endovascular 15.8% vs surgical 29.6%; p=0.237). Patients undergoing endovascular treatment were discharged earlier (endovascular 11.2 vs surgical 14.9 days; p=0.028). After surgical repair, patients received significantly more blood transfusions than endovascularly treated patients (endovascular 1.00 vs surgical 3.1 red blood cell concentrate bags; p<0.001). No differences were found regarding the new onset of walking pain, rest pain, and ischemic ulcers during follow-up.

CONCLUSION

In this retrospective cohort, endovascular treatment of access-related vascular complications of transfemoral TAVI procedures was safe and feasible. During the hospital stay, endovascularly treated patients received fewer blood transfusions and were discharged faster than surgically treated patients. No differences regarding clinical outcomes and re-intervention rates were seen during the follow-up.

CLINICAL IMPACT

Given the in this retrospective study demonstrated safety and feasibility of endovascular treatment for major access-related vascular complications, along with the in-hospital benefits and absence of follow-up disadvantages compared to surgical treatment, endovascular treatment should be considered in cases of major access-related vascular complications in transfemoral TAVI patients.

Covered Stents as a First-Line Treatment for Vascular Access Complications During Transfemoral Transcatheter Aortic Valve Implantation: Eight-Year Experience From a Single Center

We report 8-year experience with vascular access complications (VACs) after percutaneous transfemoral transcatheter aortic valve implantation (TAVI). From January 2010 to January 2018, patients with iliofemoral VAC treated by an intervention following percutaneous transfemoral TAVI were included. Major VAC was defined according to the Valve Academic Research Consortium 2 classification. As first-line strategy, VACs were treated using covered nitinol stents (CS). Among 795 percutaneous transfemoral TAVI, 74 (9.3%) patients (female, 57%; 82 ± 8 years) with VAC treated by CS and/or open repair were included in this study: 59 CS cases and 15 open repair cases. Two CS patients were converted to open repair. Technical success for stent implantation was 97%. The main VAC was a persistent bleeding related to percutaneous closure device failure (72%). Thirty-day mortality in the study cohort was 5.4% (4/74), including 1 VAC-related death. One patient had postoperative lower limb ischemia successfully treated by open repair. No amputation, new-onset claudication or in-stent occlusion was recorded. Endovascular intervention using self-expandable nitinol covered stent is safe and effective as a first-line strategy for the treatment of VAC in percutaneous transfemoral TAVI. However, open repair is needed in case of unfeasibility or failure of endovascular therapy.

[Postacute care after transcatheter aortic valve implantation (TAVI)]

With increasing age valvular heart disease is among the most frequent diseases of the heart. Relevant valvular disease impairs not only the long-term prognosis but also physical resilience, activities of daily living and the quality of life. In cases of middle to high-grade symptomatic cardiac defects, valve replacement or valve reconstruction is still the surgical procedure of choice; however, in recent years the transcatheter percutaneous aortic valve replacement (TAVI) procedure has become more prominent for the most frequent defect, aortic valve stenosis. This article provides an overview of the aftercare and rehabilitation of patients following a TAVI intervention.

Long-Term Outcomes of Iliofemoral Artery Stents after Transfemoral Aortic Valve Replacement

PURPOSE

To report long-term results of iliofemoral stent placement after transcatheter aortic valve replacement (TAVR).

MATERIALS AND METHODS

TAVR access-related complications treated with iliofemoral stent placement were recorded in 56 patients (mean age, 81 years; range; 53-93 years; 48% male) of 648 patients who underwent TAVR at a single center. Fifty-six patients treated with stent placement (40 patients with stent grafts and 16 patients with bare metal stents) underwent clinical and ultrasonographic follow-up after a mean of 676 days (range, 60-1840 days).

RESULTS

During follow-up, none of the 56 patients who had stent placement underwent a vascular reintervention of the affected limb, and none suffered from limb claudication. No decrease was observed in ankle-brachial index (ABI) values to an abnormal value, except in 1 patient (mean preprocedural and postprocedural ABI of 1.2 ± 0.14, range, 0.97-1.4 and 1.19 ± 0.24, range, 0.65-1.54, respectively). Arterial duplex assessment showed normal stent flow velocity (mean, 168.7 ± 63.2 cm/sec; range, 80-345 cm/sec) in all but 1 patient.

CONCLUSION

Iliofemoral stent implantation is a safe and efficacious treatment for vascular access site and access-related complications during transfemoral TAVR.