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Page 8 of 19 Masiero et al. Mini-invasive Surg 2022;6:4 https://dx.doi.org/10.20517/2574-1225.2021.104

confirming the importance of careful access site management in female patients undergoing TAVI (In
press).

Assessment
Access site should be thoroughly assessed by multi-slice computed tomography. CT scan can identify the
presence of peripheral vascular disease, small size of ileo-femoral vessels, severe tortuosity, and
[54]
calcifications, conditions that can increase the rate of vascular complications . In particular, the extent and
distribution of calcifications should be reported in order to plan the use of adjunctive treatments, such as
[55]
intravascular lithotripsy of peripheral vessels, or the need for an alternative route . CT scan is also of
uttermost importance in the assessment of ileo-femoral vessels dimensions, being the sheath to femoral
artery ratio (SFAR) a strong predictor of vascular complications. Female patients might have smaller vessel
diameters resulting in an unfavorable SFAR, and this might explain the higher rate of vascular
complications observed in this population [Figure 3]. If transfemoral access is not feasible, alternative
[56]
peripheral vascular approaches such as transubclavian/transaxillary/transcarotid/transapical/transaortic/tra-
nscaval (in order of importance) may be considered if the risk is deemed high and the patient is inoperable.

Puncture
Femoral puncture can be obtained using fluoroscopy guidance with contralateral angiography (FCA) or
with the use of two-dimensional ultrasound (2D-US). A recent study reported no difference in the risk of
vascular and bleeding complications according to the femoral puncture technique used [FCA vs. 2D-US:
6.7% (95%CI: 4.9%-8.9%) vs. 6.8% (95%CI: 4.8%-9.3%); P = 0.63; 6.1% (95%CI: 4.4%-8.2%) vs. 6.4% (95%CI:
4.8%-9.3%); P = 0.70 respectively] . However, it can be speculated that in specific subsets of patients (small
[57]
vessels and severe calcification), 2D-US guidance might improve patients’ outcomes.

Closure
Different vascular closure devices (VCD) have been used in order to reduce vascular complications. In a
post hoc analysis from the BRAVO-3 (Bivalirudin vs. heparin anti-coagulation in transcatheter aortic valve
replacement) trial, in comparison to the Prostar device (Abbott Vascular, Santa Clara), the use of two
Proglide devices (Abbott Vascular, Santa Clara) was associated with a lower rate of major or minor vascular
[58]
complications and lower rates of acute kidney injury in patients undergoing transfemoral TAVI . In line
with these results, the recent sub-analysis from the WIN TAVI Registry identified the use of Proglide as an
independent predictor of reduction of MVC [hazard ratio (HR) = 0.49; 95%CI: 0.28-0.84; P = 0.010] (In
press). Moreover, to increase the safety of the percutaneous closure of the primary TAVI access, the radial
modified crossover technique for controlled angiography and balloon inflation of the therapeutic access site
might be used .
[59]
In conclusion, women undergoing TAVI experience more vascular complications than their male
counterparts. MVC is related to worse clinical outcomes. A careful CT scan access assessment along with
the use of US in selected cases, a minimalistic approach with a “diagnostic” radial access, and the adequate
use of VCD for percutaneous closure of the primary access might reduce the incidence of MVC and
improve patient outcomes.

Device selection
In recent years, the continuous technological evolution guided by a growing clinical experience has led to
the development of new iterations of preexisting THV platforms and newly designed THV systems, with
subsequent improvement in valve hemodynamic and reduction in procedural complications. Moreover,
with the advent of multimodal three-dimensional imaging (in particular, CT scan) as the gold standard in