DIRECT VESSEL VISUALIZATION WITH ARTERIAL CUT-DOWN REDUCES VASCULAR COMPLICATION RATES IN TRANSCATHETER AORTIC VALVE IMPLANTATION: BACK TO THE FUTURE

Abstract

Transfemoral (TF) transcatheter aortic valve implantation (TAVI) using a purely percutaneous approach is associated with significant rates of major vascular complications, even in the most contemporary published data series. The rate of major vascular complications in the TAVI group in the US CoreValve High Risk Study was 5.9%. Since 2010 our institution has adopted a routine surgically performed vascular cut-down for all TF TAVI procedures with deployment of a balloon expandable sheath (SoloPath, Onset Medical Corp, Irvine, CA) under direct arterial visualization. The purpose of this retrospective observational study was to document the rate of vascular complications using this approach. Records on patients who underwent TF TAVI with the CoreValve system (Medtronic, Minneapolis, MN) between January 2010 to March 2014 at our centre were retrospectively reviewed. Data on patient demographics, STS scores, femoral artery size, procedure duration, mortality, vascular complications, transfusions, wound infections, length of stay and discharge location were collected. Vascular complications were defined according to the Valve Academic Research Consortium definitions. Descriptive statistics were performed. Sixty-three patients underwent TF TAVI from January 2010 to March 2014. The mean age was 80 years. Seventy percent were male. The mean STS score for morbidity and mortality was 27.7 ± 13%. The mean STS PROM score was 7.5 ± 5.5%. The mean diameter of the common femoral artery was 8.8 ± 1.6mm. All patients had a TF approach with direct arterial visualization via cut-down. The mean procedural duration was 132 ± 53mins. There was a 4.8% 30-day mortality rate. One vascular complication (1.6%, 1/63) was observed. A localized sub-intimal lower descending thoracic aortic dissection was identified following sheath insertion which necessitated aborting the procedure. This healed uneventfully and a subsequent successful transapical TAVI was undertaken 6 weeks later. There were no complications of leg ischemia, hemorrhage, or iliofemoral rupture. Four patients (6.3%) required transfusions of at least 1 unit due to peri-procedural blood loss. One patient (1.6%) experienced a pseudomonas wound infection that resolved with intravenous inpatient antibiotic treatment. Mean length of stay was 6.4 ± 3.5days and 94% (59/63) were discharged to their own homes. Use of direct arterial visualization and a balloon expandable sheath system for obtaining femoral vascular access for TAVI was associated with a vascular complication rate substantially lower than that seen in published studies using a purely or default percutaneous approach while maintaining a comparable length of hospital stay.