Page 20 - Read Online

Page 2 of 19 Khokhar et al. Mini-invasive Surg 2022;6:2 https://dx.doi.org/10.20517/2574-1225.2021.97

long-term morbidity and mortality, is therefore crucial. This review aims to provide interventionists with a
practical guide for the prevention and management of important peri-procedural complications during
TAVR.

VASCULAR COMPLICATIONS
Vascular complications encompass a wide spectrum of conditions, including damage to aortic and
ventricular structures or peripheral access site-related injuries, with the latter being the focus of this
[1]
section . Development of a vascular complication is associated with increased morbidity, mortality, and
[2,3]
length of hospital stay and worsening quality of life . Despite improvements in operator experience, pre-
procedural planning, procedural access and closure techniques, and dramatic reductions in valve profiles,
[4-7]
the rate of major vascular complications in contemporary cohorts still ranges 5%-10% . Furthermore, the
fact that TAVR is inferior to surgical aortic valve replacement (SAVR) in terms of vascular complications
[4]
will become increasingly relevant as TAVR expands to lower-risk younger patients . Therefore, this section
focuses on the practical pre-procedural and intra-procedural steps that should be considered in order to
reduce the incidence and impact of any vascular complications.

Preventing vascular complications
A detailed evaluation of the peripheral vessels using pre-procedural multi-slice computed tomography
(MSCT) is critical to reducing the risk of vascular complications. The following variables should be
examined: minimal lumen diameters of the iliac and femoral vessels (> 5.5 mm), ilio-femoral vessel
tortuosity, vessel calcification location, length and arc, location of femoral bifurcation, and presence of any
additional vascular pathology [8-10] . When feasible, trans-radial access can be considered for the contralateral
diagnostic approach and is associated with a significant reduction in vascular complications compared to a
conventional bi-femoral approach [11,12] .

In the presence of severe, ilio-femoral calcific stenosis, peripheral intravascular lithotripsy (IVL) may
facilitate trans-femoral access. Among 42 patients with unfavorable ilio-femoral anatomy, use of IVL
facilitated a successful trans-femoral procedure in 90% of cases, with only two patients developing vascular
complications (pseudoaneurysm and requirement for endarterectomy) . If, however, both ilio-femoral
[13]
access routes are not feasible, then an MSCT evaluation of alternative access sites should be undertaken. The
most frequent non-transfemoral approaches include trans-carotid and trans-axillary approaches [14-16] . Data
from the FRANCE transcatheter aortic valve implantation (TAVI) registry show that the use of trans-
axillary and trans-carotid access was associated with similar rates of mortality and access site complications
and a lower rate of major vascular complications and unplanned vascular repairs compared to transfemoral
access . In patients with no peripheral access option available, trans-caval access can be considered and
[15]
initial experience is promising with procedural and device success occurring in 99/100 patients [17,18] . Rates of
Valve Academic Research Consortium (VARC)-2 bleeding and major vascular complications were 7% and
13% in this population cohort. Finally, if no percutaneous solutions are possible, then direct surgical access
can be considered, as either a cut-down approach to the axillary or carotid arteries or a more traditional
aortic access via mini-thoracotomy.

Access site management
Using the pre-procedural computed tomography (CT), the optimal site for arterial puncture can be
determined. Use of real-time ultrasound guidance is increasing and is associated with a reduction in the
incidence of vascular complications . Ultrasound can assist in localization of the femoral bifurcation and
[19]
presence of anterior wall calcification. Adjunctive techniques include “road-mapping” the femoral puncture
site by performing a diagnostic angiogram from the contralateral site. Adequate preparation of the sub-