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Masiero et al. Mini-invasive Surg 2022;6:4 https://dx.doi.org/10.20517/2574-1225.2021.104 Page 11 of 19

vascular complications obtained with FlexNav DS is below 5% in a cohort of high-risk/extreme-risk subjects
treated with this device: this compares very well to the low-risk cohort of patients enrolled in the Evolut
[73]
low-risk trial and in Partner 3 trial (rate of major vascular complications of 3.8% and 2.0%, respectively) .
The Sapien 3/Ultra THVs can be implanted using a dedicated 14 or 16 Fr expandable eSheath technology,
which temporarily expands as the device passes through the iliofemoral vessels (minimum diameter 5.5 mm
for size 20, 23, and 26 mm) and then recoils to its smaller caliber. All details about annulus covering range,
delivery sheath size, and minimum vessels diameter requirements for different THVs are provided in
Figure 4 [63,74] .

Procedural tricks
While performing a TAVI in women, several precautions related to the anatomical specificities discussed
above should be kept in might [Figure 5].

First, the risk of major complications is higher and is associated with worse prognosis [51,52] . The small
vascular diameter and the calcifications are two of the major reasons for these complications. Efforts should
be made to optimize vascular assessment on CT scan before the procedure, and an alternative route should
be considered if the risk is deemed high. When a femoral access has been selected, while there was no
proven advantage of 2D-US over FCA for vascular puncture guidance , combining both techniques can be
[57]
considered in some cases to increase procedural safety, preferably using radial modified crossover
technique. Prostar should be avoided, probably replaced by the use of two Proglide devices, as discussed
above, while awaiting more data regarding the potential advantage of other devices such as Manta in
women. In the case of heavy calcifications, intravascular lithotripsy should be considered. Choosing a device
with low-profile delivery system, as discussed above, should be privileged. Finally, the risk of venous
vascular complications should not be neglected, and over-the-wire rapid pacing should be preferred to the
insertion of a temporary pacing probe when possible.

Another important aspect is related to aortic valve and root size and configuration. The combination of
small body surface area, small anatomic root, and a low coronary take-off, which are all more frequent in
women, should influence the choice of valve type as well as the procedure itself. As discussed above, supra-
annular self-expanding valves can help reduce the risk of transvalvular gradient, and commissural
alignment should be targeted to allow future coronary arteries catheterization.

Moreover, taking into account the longer life expectancy of women, it is particularly advisable to customize
the implantation strategy of supra-annular THV (when selected) in order to foresee future valve re-
intervention. Accordingly, the implantation level of the prosthesis should ensue from the trade-off of the
pace-maker risk at the first procedure and the sinus sequestration at the future TAVI-in-TAVI intervention.
In patients with a high risk of coronary obstruction due to coronary take-off, coronary protection should be
realized using the chimney technique, with the catheterization of the jeopardized coronary and positioning
a wire and a stent distally, before inserting the valve. The use of transcatheter electrosurgery for aortic leaflet
laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is also a promising alternative .
[57]

Finally, a frequent encounter among women is the presence of a small left ventricular cavity which might
increase the risk of perforation. Choosing the appropriate wire and, more importantly, the appropriate
distal end shape, is paramount to allow safe anchoring into the ventricle. For operators who are used to
shaping their own wire tip, a smaller loop should be applied to the distal end. Otherwise, choosing dedicated
pre-shaped stiff guidewire with a small curve is a tempting alternative, allowing a safer procedure. For
example, the Amplatz Extra-Stiff APEX wire has a double curve design composed of a larger curve with the