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.
HageFHarrisARClercO, et al. Transfemoral versus transapical approach for transcatheter aortic valve implantation: a systematic review and meta-analysis of adjusted studies. Eur Heart J. 2021;42(suppl 1):ehab724.1624. doi:10.1093/eurheartj/ehab724.1624.
2.
FarouxLJunqueraLMohammadiS, et al. Femoral versus nonfemoral subclavian/carotid arterial access route for transcatheter aortic valve replacement: a systematic review and meta-analysis. J Am Heart Assoc. 2020;9(19):e017460. doi:10.1161/JAHA.120.017460.
3.
AbdelazizHKMegalyMDebskiM, et al. Meta-analysis comparing percutaneous to surgical access in trans-femoral transcatheter aortic valve implantation. Am J Cardiol. 2020;125(8):1239–1248.
4.
EcknerDPollariFSantarpinoG, et al. Comparison between surgical access and percutaneous closure device in 787 patients undergoing transcatheter aortic valve replacement. J Clin Med. 2021;10(7):1344. https://pubmed.ncbi.nlm.nih.gov/33805069. Accessed September 22, 2023.
5.
AtesICilingirogluM.Percutaneous access versus surgical cut down for TAVR: where do we go from here?Catheter Cardiovasc Interv. 2018;91(7):1363–1364. http://europepmc.org/abstract/MED/29894594. Accessed September 22, 2023.
6.
SherwoodMWXiangKMatsouakaR, et al. Incidence, temporal trends, and associated outcomes of vascular and bleeding complications in patients undergoing transfemoral transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2020;13(1):e008227. doi:10.1161/CIRCINTERVENTIONS.119.008227.
7.
BhushanSHuangXLiY, et al. Paravalvular leak after transcatheter aortic valve implantation its incidence, diagnosis, clinical implications, prevention, management, and future perspectives: a review article. Curr Probl Cardiol. 2022;47(10):100957. https://www.sciencedirect.com/science/article/pii/S0146280621001729. Accessed September 22, 2023.
8.
HuangHDMansourM.Pacemaker implantation after transcatheter aortic valve replacement: a necessary evil perhaps but are we making progress?J Am Heart Assoc. 2020;9(9):e016700. doi:10.1161/JAHA.120.016700.
9.
LangouetQMartinezRSaint-EtienneC, et al. Incidence, predictors, impact, and treatment of vascular complications after transcatheter aortic valve implantation in a modern prospective cohort under real conditions. J Vasc Surg. 2020;72(6):2120–2129.e2. https://www.sciencedirect.com/science/article/pii/S0741521420304894. Accessed September 22, 2023.
10.
ChangalKHSyedMADarT, et al. Systematic review and proportional meta-analysis of endarterectomy and endovascular therapy with routine or selective stenting for common femoral artery atherosclerotic disease. J Interv Cardiol. 2019;2019:1593401. https://pubmed.ncbi.nlm.nih.gov/31772513. Accessed September 22, 2023.
11.
Ben AbdallahIUrenaMSutterW, et al. Covered stents as a first-line treatment for vascular access complications during transfemoral transcatheter aortic valve implantation: eight-year experience from a single center. Angiology. 2020;72(1):70–77. doi:10.1177/0003319720950148.
12.
GrossmanYSilverbergDBerkovitchA, et al. Long-term outcomes of iliofemoral artery stents after transfemoral aortic valve replacement. J Vasc Interv Radiol. 2018;29(12):1733–1740. doi:10.1016/j.jvir.2018.06.003.
13.
GénéreuxPPiazzaNAluMC, et al. Valve academic research consortium 3: updated endpoint definitions for aortic valve clinical research. J Am Coll Cardiol. 2021;77(21):2717–2746. doi:10.1016/j.jacc.2021.02.038.
14.
SzilagyiDESmithRFElliottJP, et al. Infection in arterial reconstruction with synthetic grafts. Ann Surg. 1972;176(3):321–333.
15.
DumpiesOKitamuraMMajunkeN, et al. Manta versus Perclose ProGlide vascular closure device after transcatheter aortic valve implantation: initial experience from a large European center. Cardiovasc Revasc Med. 2022;37:34–40. https://www.sciencedirect.com/science/article/pii/S1553838921005054. Accessed September 22, 2023.
16.
StorteckySWenaweserPDiehmN, et al. Percutaneous management of vascular complications in patients undergoing transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2012;5(5):515–524. https://www.sciencedirect.com/science/article/pii/S193687981200249X. Accessed September 22, 2023.
17.
VeulemansVAfzalSLedwigP, et al. Stent fractures after common femoral artery bail-out stenting due to suture device failure in TAVR. Vasa. 2018;47(5):393–401. doi:10.1024/0301-1526/a000712.
18.
SedaghatANeumannNSchahabN, et al. Routine endovascular treatment with a stent graft for access-site and access-related vascular injury in transfemoral transcatheter aortic valve implantation. Circ Cardiovasc Interv. 2016;9(8):e003834. doi:10.1161/CIRCINTERVENTIONS.116.003834.
19.
De BackerOArnousSSandholtB, et al. Safety and efficacy of using the viabahn endoprosthesis for percutaneous treatment of vascular access complications after transfemoral aortic valve implantation. Am J Cardiol. 2015;115(8):1123–1129. doi:10.1016/j.amjcard.2015.01.547.
20.
UedaTMurataSTajimaH, et al. Emergency endovascular treatment using a Viabahn stent graft for upper and lower extremity arterial bleeding: a retrospective study. CVIR Endovasc. 2021;4(1):83. https://pubmed.ncbi.nlm.nih.gov/34882296. Accessed September 22, 2023.
21.
HegerTStraußSBlessingE, et al. Short and long-term results after endovascular management of vascular complications during transfemoral aortic valve implantation. Acta Cardiol. 2017;72(4):474–482. doi:10.1080/00015385.2017.1335455.
22.
GouëfficYDella SchiavaNThaveauF, et al. Stenting or surgery for de novo common femoral artery stenosis. JACC Cardiovasc Interv. 2017;10(13):1344–1354.
23.
OhkiTKichikawaKYokoiH, et al. Outcomes of the Japanese multicenter Viabahn trial of endovascular stent grafting for superficial femoral artery lesions. J Vasc Surg. 2017;66(1):130–142.e1.
24.
ReijnenMMPJvan WalravenLAFritschyWM, et al. 1-year results of a multicenter randomized controlled trial comparing heparin-bonded endoluminal to femoropopliteal bypass. JACC Cardiovasc Interv. 2017;10(22):2320–2331.
25.
MohrBASheenALRoy-ChaudhuryP, et al. Clinical and economic benefits of stent grafts in dysfunctional and thrombosed hemodialysis access graft circuits in the REVISE randomized trial. J Vasc Interv Radiol. 2019;30(2):203–211.e4.
26.
ThieleHKurzTFeistritzerH-J, et al. General versus local anesthesia with conscious sedation in transcatheter aortic valve implantation. Circulation. 2020;142(15):1437–1447. doi:10.1161/CIRCULATIONAHA.120.046451.
27.
MaasEHAPietersBMAVan de VeldeM, et al. General or local anesthesia for TAVI? a systematic review of the literature and meta-analysis. Curr Pharm Des. 2016;22(13):1868–1878.
28.
KuySDuaADesaiS, et al. Surgical site infections after lower extremity revascularization procedures involving groin incisions. Ann Vasc Surg. 2014;28(1):53–58.
29.
KronlageMErbelCLichtenbergM, et al. Safety and effectiveness of Phoenix atherectomy for endovascular treatment in calcified common femoral artery lesions. Vasa. 2021;50(5):378–386. doi:10.1024/0301-1526/a000960.
30.
TraniCRussoGAurigemmaC, et al. The conundrum of endovascular common femoral artery treatment: a case report of lithoplasty as a viable solution. Eur Heart J. 2019;3:ytz122.
31.
ShammasNWAbi DoumetAKariaR, et al. An overview of the treatment of symptomatic common femoral artery lesions with a focus on endovascular therapy. Vasc Health Risk Manag. 2020;16:67–73.
32.
MachMOkutucuSKerbelT, et al. Vascular complications in TAVR: incidence, clinical impact, and management. J Clin Med. 2021;10(21):5046. https://pubmed.ncbi.nlm.nih.gov/34768565. Accessed September 22, 2023.
33.
LuxAMüllenbergLVeenstraLF, et al. Iliofemoral tortuosity increases the risk of access-site-related complications after aortic valve implantation and plug-based access-site closure. CJC Open. 2022;4(7):609–616. https://www.sciencedirect.com/science/article/pii/S2589790X22000543. Accessed September 22, 2023.
34.
MeertensMMTenorioERLemmensCC, et al. Safety of percutaneous femoral access for endovascular aortic aneurysm repair through previously surgically exposed or repaired femoral arteries. J Endovasc Ther. 2022;30:730–738. doi:10.1177/15266028221092980.
35.
DenckerDTaudorfMLukNHV, et al. Frequency and effect of access-related vascular injury and subsequent vascular intervention after transcatheter aortic valve replacement. Am J Cardiol. 2016;15:1244–1250.
36.
MwipatayiBPPicardoAMasilonyane-JonesTV, et al. Incidence and prognosis of vascular complications after transcatheter aortic valve implantation. J Vasc Surg. 2013;58(4):1028–1036.e1. doi:10.1016/j.jvs.2013.03.046.
37.
VincentFSpillemaekerHKyhengM, et al. Ultrasound guidance to reduce vascular and bleeding complications of percutaneous transfemoral transcatheter aortic valve replacement: a propensity score–matched comparison. J Am Heart Assoc. 2020;9(6):e014916. doi:10.1161/JAHA.119.014916.
38.
Al-KassouBKandtJLohdeL, et al. Safety and efficacy of protamine administration for prevention of bleeding complications in patients undergoing TAVR. JACC Cardiovasc Interv. 2020;13(12):1471–1480. https://www.sciencedirect.com/science/article/pii/S193687982030858X. Accessed September 22, 2023.
